Recent posts tagged postmortem

One keystroke, one wrong unit, and a share registry created thirty-one times the company it was keeping the books for. The interesting part is not the typo. It is that nothing in the crediting path compared the credit against issuance, and the conser...

A brilliant investigation and a perfunctory one converge on the same three weak fixes. The analysis explains the last failure. Only the tracker, and the engineering it forces, gets a vote on the next one. In 2017, a team of patient-safety research...